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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781, <br /> APPLICATION FOR WELT, CONSTRUCTION OR`PUMP 'PERMIT Permit No. -2oa- Z <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ' <br /> 0 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and1:the Rules and Regulations of the San Joaquin Local Health District. i <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name W Phone 3 <br /> f <br /> Address I 12---6 k9j oeo-,d city <br /> ease Phone, <br /> Contractor's Name . t-1-5 � 4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / �R°ECONDITION / / DESTRUCTION 1-7- <br /> PUMP <br /> 7PUMP INSTALLA_TI0>- U1-T REPAIR I I PUMP REPLACEMENT,7-1- 4 � )j ' <br /> Other <br /> �/x,�,���►- <br /> DISTANCE TO NEAREST: SEPTICFT- .: SEWER LINES PIT PRIVY <br /> SEWAGO ISEOSAL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> PROP -P LINE -PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE -` TYPE OF WELL---iXl CONSTRUCTION SPECIFICATIONS <br /> Industrial 'G'ab'le Tool Dia. of Well Excavation <br /> Domestic/pr mate � . '�•Dri-lled Dia. of Well Casing <br /> Domestac/gublic`� ' '1�` _„Driyen Gauge of Casing <br /> Lr gation _ "` Gravel Pack Depth of Grout Seal <br /> T e o£ Grout <br /> _ Cathodic Protection ""� Rotary yp a <br /> f•-Disposal `'^464 Other Other Information <br /> ,� Geophysical �^ Surface Seal Installed B <br /> ol <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done '40 <br /> PUMP .REPAIR:, . / / State Wokk-,Done <br />` DES-TRUCTION OF WELL: Well Diametier:', - ' " Approximate Depth <br />{ Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating well •'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE I; <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE I /' DATE A <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTiINSPECTION PHASE III/FINAL INSPECTION r <br /> r INSPECTION BY DATE INSPECTION BY DATES <br /> yi-s OA 9 <br /> 11177 <br /> 'f 77 <br />